ATI RN
ATI Mental Health Practice B
1. A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?
- A. Your behavior is part of your illness, and it is important to work on changing it.
- B. It is important to understand why you feel the need to perform these behaviors.
- C. Let's figure out a way for you to control these behaviors.
- D. It sounds like you are feeling powerless to change your behavior.
Correct answer: D
Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.
2. When a patient with major depressive disorder is prescribed escitalopram, what potential side effect should the healthcare provider educate the patient about?
- A. Weight gain
- B. Insomnia
- C. Diarrhea
- D. Hypertension
Correct answer: B
Rationale: The correct answer is B: Insomnia. Escitalopram, a selective serotonin reuptake inhibitor (SSRI), commonly causes insomnia as a side effect. Patients should be informed about the possibility of experiencing difficulty falling or staying asleep when starting this medication. Choices A, C, and D are incorrect because weight gain, diarrhea, and hypertension are not typically associated with escitalopram use.
3. When assessing a patient with generalized anxiety disorder (GAD), which symptom would a nurse most likely observe?
- A. Flashbacks
- B. Excessive worry
- C. Hallucinations
- D. Compulsive behaviors
Correct answer: B
Rationale: Excessive worry is a primary characteristic of generalized anxiety disorder (GAD). Patients with GAD experience persistent and excessive worry about various aspects of their lives, often anticipating disaster or catastrophic outcomes. This worry is difficult to control and can be accompanied by physical symptoms like restlessness, fatigue, irritability, muscle tension, and difficulty concentrating. Flashbacks are more commonly associated with post-traumatic stress disorder (PTSD), hallucinations are more typical of psychotic disorders, and compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD). Therefore, when assessing a patient with GAD, a nurse would most likely observe excessive worry.
4. A patient with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate?
- A. Encourage the patient to ignore the voices.
- B. Provide a structured and safe environment.
- C. Engage the patient in a debate about the reality of the voices.
- D. Ask the patient to describe the content of the hallucinations.
Correct answer: D
Rationale: The most appropriate nursing intervention when a patient with schizophrenia is experiencing auditory hallucinations is to ask the patient to describe the content of the hallucinations. This intervention helps assess the risk associated with the hallucinations and provides valuable insight into the patient's condition, aiding in developing an effective care plan. Encouraging the patient to ignore the voices (Choice A) may not address the underlying issues or risks associated with the hallucinations. Providing a structured and safe environment (Choice B) is important but does not directly address the hallucinations. Engaging the patient in a debate about the reality of the voices (Choice C) may worsen the situation by invalidating the patient's experiences.
5. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms?
- A. 3.7
- B. 1.7
- C. 2.6
- D. 1.3
Correct answer: B
Rationale: Symptoms such as blurred vision, tinnitus, and severe diarrhea are indicative of lithium toxicity. A lithium level of 1.7 is within the toxic range. When clients present with these symptoms, it is crucial for the nurse to correlate them with elevated lithium levels to ensure timely intervention and prevent further complications.
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